Revised Clinical Institute Withdrawal Assessment for alcohol

• Scale that measures the severity of alcohol withdrawal symptoms
• See also the MDCalc CIWA-Ar calculator

Administration

• Use open-ended questions for each item
• Assess hourly for the first three hours and also for those who score above 10
  • If a patient scores below 10 for three hours in a row, assessment every four hours thereafter is reasonable
• Begin treating patients once they score above 10
  • Consider prophylactic treatment regardless of CIWA for patients at high risk for severe withdrawal
• Reassess an hour after any score above 10 where they were given diazepam

Criteria

Criterion	0	1	2	3	4	5	6	7
Nausea and vomiting Ask, "Do you feel sick to your stomach? Have you vomited?" Observation	no nausea and no vomiting	mild nausea with no vomiting			intermittent nausea with dry heaves			constant nausea, frequent drug heaves and vomiting
Tremor Arms extended and fingers apart. Observation.	no tremor	not visible, but can be felt fingertip-to-fingertip			moderate, with patient's arms extended			severe, even with arms not extended
Paroxysmal sweats Observation	no sweat visible	barely perceptible sweating, palms moist			beads of sweat obvious on forehead			drenching sweats
Anxiety Ask, "Do you feel nervous?" Observation.	no anxiety, at ease	mildly anxious			moderately anxious, or guarded, so anxiety is inferred			equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions
Agitation Observation.	normal activity	somewhat more than normal activity			moderately fidgety and restless			paces back and forth during most of the interview, or constantly thrashes about
Tactile disturbances Ask, "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Observation.	none	very mild itching, pins and needles, burning or numbness	mild itching, pins and needles, burning or numbness	moderate itching, pins and needles, burning or numbness	moderately severe hallucinations	severe hallucinations	extremely severe hallucinations	continuous hallucinations
Auditory disturbances Ask, "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation.	not present	very mild harshness or ability to frighten	mild harshness or ability to frighten	moderate harshness or ability to frighten	moderately severe hallucinations	severe hallucinations	extremely severe hallucinations	continuous hallucinations
Visual disturbances Ask, "Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation.	not present	very mild sensitivity	mild sensitivity	moderate sensitivity	moderately severe hallucinations	severe hallucinations	extremely severe hallucinations	continuous hallucinations
Headache, fullness in head Ask, "Does you head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity.	not present	very mild	mild	moderate	moderately severe	severe	very severe	extremely severe
Orientation and clouding of sensorium Ask, "What day is this? Where are you? Who am I?"	oriented and can do serial additions	cannot do serial additions or is uncertain about date	disoriented for date by no more than 2 calendar days	disoriented for date by more than 2 calendar days	disoriented for place and/or person
Criterion	0	1	2	3	4	5	6	7

Interpretation

Score	Severity
0 to 9	Very mild or absent
10 to 15	Mild
16 to 20	Moderate
21 to 67	Severe

Further Reading

• Assessment of Alcohol Withdrawal: The Revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). Br J Addict. 1989;84(11):1353-1357. doi: 10.1111/j.1360-0443.1989.tb00737.x